JOHN DICKERSON: Let me ask you about health care -- Tucker Carlson interviewed you about six weeks ago when you were in the middle of health care negotiations. And you agreed with him that the health care bill wasn't going to help your supporters. That those who lived in rural areas, the older, were going to get hurt by that bill. And you told him--

PRESIDENT DONALD TRUMP: Excuse me, the health care bill is going to help my supporters.

"F*ck anyone who didn't support me, though."

JOHN DICKERSON: Well, hold on. Let me just finish the question, if I may, sir--

PRESIDENT DONALD TRUMP: Otherwise, I'm not going to sign it. I'm not going to do it.

JOHN DICKERSON: Well, this is why I wanted to ask you. You said to Tucker, "We will take care of our people, or I am not signing it." You said you were going to negotiate.

PRESIDENT DONALD TRUMP: Well, that's what I just said.

JOHN DICKERSON: So tell me what in the bill you've been negotiating to get--

California’s premiums could rise by 28 to 49 percent in 2018, and up to 340,000 consumers could lose individual market coverage if changes are made to existing federal policies.

The potential rate increase would mean billions of dollars in additional federal spending. The 1.2 million consumers who do not receive subsidieswould bear the entire brunt of these increases.

The potential decrease of 340,000 insured consumers would not only represent many individuals losing access to potentially life-saving care, but it would result in a sicker risk mix in the individual market and higher premiums for everyone.

SACRAMENTO, Calif. — A new analysis shows the dramatic consequences facing Californians if federal policies are changed from the current structure and there is no longer direct federal funding of cost-sharing reduction (CSR) reimbursements and the individual shared responsibility payment is not enforced when a consumer chooses not to purchase coverage.

The analysis found that Covered California health plan premiums could rise up to 49 percent if two key elements that have been in place for the past four years are changed: Cost-sharing reduction reimbursements are no longer directly funded as reimbursements to carriers, and the shared individual responsibility payment is not enforced.

I noted a week or so ago that according to David Anderson of Balloon Juice, rumor has it that many insurance carriers are making their actuaries work overtime to put together multiple rate filings for 2018 based on several different outlooks:

A couple of weeks ago I noted that a buttload of heavy players in the healthcare field sent a joint letter to Trump, Tom Price and everyone else under the sun making it pretty clear how vital resolving the CSR issue is, and what the consequences would be if Congress and Trump don't make good on them.

Today, Molina Healthcare, which has around 1 million ACA exchange enrollees at the moment (roughly 9% of all effectuated enrollees) lowered the boom even harder (via Bob Herman of Axios):

UPDATE 7/18/17: Now that BCRAP appears to be dead (by no means a certainty...the vote is STILL scheduled for next week), it's time to update/clean up this list a bit and bring it to the forefront for awhile.

For months now, throughout the Trumpcare/AHCA/BCRAP/ crisis, people have been asking me "How would YOU fix the Affordable Care Act?" I've given my answer repeatedly, in bits and pieces, and even given the basics in a few tweetstorms, it's time to bring it all together.

The Trump administration has told Democrats it will continue paying controversial ObamaCare insurer subsidies, lowering fears that a fight over the issue could cause a government shutdown.

The move marks something of a shift for President Trump, who had threatened earlier this month to withhold the subsidies, known as cost-sharing reductions, as a way to move Democrats to negotiate on a healthcare overhaul.

"A shift"? He shifts so often he should be in the next Fast & Furious movie.

Rep. Tony Cardenas (D-Calif.), for one, said Wednesday that he doesn’t trust the president enough to take him at his word.

With the future of any other replacement plans uncertain, this month’s survey also gauges who the public views as responsible for the 2010 health care law going forward. A majority (61 percent) of the public say that because President Trump and Republicans in Congress are in control of the government, they are now responsible for any problems with the ACA moving forward. About three in ten Americans (31 percent) say that because President Obama and Democrats in Congress passed the law, they are responsible for any problems with it.

UPDATE 7/17/17: Dusting it off AGAIN because with the Senate GOP's #BCRAP replacement bill supposedly dead, Mitch McConnell is now claiming he's gonna go back to "Repeal/Delay", while Trump is once again threatening to simply "let Obamacare fail completely"...which CSR sabotage would definitely be a part of. Simply substitute the month of "AUGUST" for "MAY" in the entry below.

UPDATE 7/29/17: OK, BCRAP is dead but now Trump is really pissed off and is openly promising (not just threatening) to cut off CSR payments starting in August, which means the following scenario could kick in effective SEPTEMBER.

(sigh) Yes, this is the third time I've used the exact same clip from "Dead Again". That's no coincidence; Zombie Trumpcare keeps shuffling back every few weeks, but this time they appear to actually be serious about it (again).

In strategy and substance, the American public disagrees with the course that President Trump and congressional Republicans are pursuing to replace the Affordable Care Act with conservative policies, according to a new Washington Post-ABC News poll.

Large majorities oppose the ideas at the heart of the most recent GOP negotiations to forge a plan that could pass in the House.

...Public sentiment is particularly lopsided in favor of an aspect of the current health-care law that blocks insurers from charging more or denying coverage to customers with medical conditions. Roughly 8 in 10 Democrats, 7 in 10 independents and even a slight majority of Republicans say that should continue to be a national mandate...

A new Kaiser Family Foundation analysis finds that the average premium for a benchmark silver plan in Affordable Care Act (ACA) marketplaces would need to increase by an estimated 19 percent for insurers to compensate for lost funding if they don’t receive federal payment for ACA cost-sharing subsidies.

Again, that's an average onf 19% on top of whatever the carriers would otherwise be increasing rates for other reasons.

The feds would have to approve the state's waiver proposal in order to enact the governor's plan, but the feds will only move forward if legislation is already in place. That's the reason for the special session: The governor will ask the legislature to pass laws granting him the authority to seek the waiver and his plan will be spelled out, in broad terms, in legislative language in these laws. Most expect that the governor will be able to get legislative approval relatively easily (he needs a simple majority). Note that some of the fine print will still have to wait for the state's actual waiver proposal and the terms and conditions if the Trump administration grants the waiver.

Here are some of the changes that Hutchinson will be pushing in the special session:

I used to write about Kentucky quite a bit shortly after incoming GOP Governor Matt Bevin made good on his promise to disassemble their beloved and award-winning "kynect" state ACA exchange. I haven't written much about the state since then, however, until now.

Bevin made two major campaign promises while running to replace former Democratic Governor Steve Beshear (who expanded Medicaid and established kynect via executive order): He said he'd kill kynect and get rid of ACA Medicaid expansion. He stuck to his guns on the former, and while it's a damned shame that he did so for a number of reasons (it was working perfectly well, had a high public image and awareness, etc), it didn't cause too much damage, since KY simply shifted to the federal exchange instead (HealthCare.Gov). Enrollment did drop off by over 13% year over year, but a few other states saw similar drops, so the move probably wasn't a major factor.

As I posted yesterday, here's a rough overview of what total Individual Market Enrollment has looked like since 2010, and how Trump's threat to cut-off CSR reimbursements would impact it:

The blue section is off-exchange enrollees...around 7 million people today, all of whom are paying full price. This includes perhaps 1.8 million people still enrolled in Grandfathered or Transitional plans (which are part of a separate risk pool), although that number is highly speculative.

A couple of weeks ago, I crunched the numbers from a major state-by-state study by the Milliman actuarial firm and concluded that the overall individual market was somewhat smaller than I had previously thought, and was likely around 17.7 million people total as of today. The key thing to keep in mind is that the enrollment numbers can fluctuate quite a bit over the course of the year due to the high churn rate and other factors. As a result, the average annual enrollment can be quite different from the snapshot in time total.

If you enroll in an ACA exchange policy via HealthCare.Gov (or any of the state-based exchanges), you have three options for the Advance Premium Tax Credits:

You can decline to even see if you're eligible (if your income is high enough that you're certain that you won't qualify)

You can see if you're eligible, and if so, choose to apply some or all of the APTC directly to your monthly premium

You can see if you're eligible, and if so, choose not to apply any of the APTC to your monthly premium, choosing instead to pay full price up front and then receive the full annual tax credit when filing your taxes the following year.

Well THAT figures: Insurance carriers finally breaking even on ACA exchanges just in time for GOP to tear up the law.

Health insurers may finally be seeing improved results on their Obamacare plans just as a newly elected president is poised to follow through on promises to end the controversial coverage program, a new report suggests.

An analysis out Thursday says that health insurers are expected in 2016 "to start reversing" financial losses on their Obamacare business after "hitting bottom" in 2015.

And 2017 "will likely see continued improvement" for those insurers selling individual health plans, "with more insurers getting close to breakeven or better," according to the report by Standard and Poor's Global Ratings.

Last year Virginia was the first state out of the gate with their initial 2017 individual & small group market rate filings. I'm not sure if this is chance or if they simply have the earliest filing deadline. I'm guessing the latter, because, as Zach Tracer noted earlier today, Virginia is again the first state to list their 2018 Individual and Small Group Market participants. Remember, these are initial filings only, and very much subject to change throughout the summer and early fall. Here's who Tracer says has stated is committing to being on the ACA exchanges this fall...at the moment, anyway:

UPDATE: ...or, perhaps not. Latest word is that there's basically little to see here; lots of big talk about pushing forward but very little action. Or perhaps there will be next week, who the heck knows? Wash, rinse, repeat.

As far as I can tell, even the amazing Louise Norris hasn't caught this one yet (and it's a month old, too!). If I'm wrong and she has done a write-up on it, of course, I'll eat my words:

Medicaid for all

Democratic [Nevada] Assemblyman Mike Sprinkle has introduced a bill, AB374, to open up the state’s Medicaid program to anyone, regardless of their income level.

Individuals would be able to purchase coverage through Medicaid on the healthcare exchange for an annual premium set at 150 percent of the median expenditure paid on behalf of Medicaid enrollees in the preceding fiscal year. Though none of the current federal or state dollars going to fund Medicaid would be used to cover any portion of the new enrollees, they would still be entitled to the same benefits provided to other Medicaid recipients.

If you can't hear it, here's the transcript of California Democratic U.S. Senator Diane Feinstein's response when asked how (not if, mind you...how) she would support moving to a Single Payer healthcare system:

She starts out by making an incredibly tone-deaf and inaccurate statement about single payer:

"If by ‘single payer’ you mean that it’s going to be a complete takeover by the government, of healthcare, then I am not there.

As most people know by now (well, most people in Tennessee, anyway), Humana decided a full two months ago to bail on the entire individual market, across the board--every state, both on and off the exchange, the works. This stung in quite a few counties across 11 different states, but the one which everyone is freaking out about is Tennessee...because there are 16 counties where Humana was the only carrier participating on the ACA exchange. Here's the list of Tennessee counties Humana is available in this year; note that there's an additional 14 counties where there's one other carrier available at the moment.

As of 2017, Hawaii no longer has a SHOP exchange for small businesses. The State Department of Labor and Industrial Relations has an FAQ page about this.

...Hawaii’s waiver aligns the ACA with the state’s existing Prepaid Health Care Act. Under the Prepaid Healthcare Act, employees who work at least 20 hours a week have to be offered employer-sponsored health insurance, and can’t be asked to pay more than 1.5 percent of their wages for employee-only coverage (as opposed to 9.69 percent under the ACA in 2017).

...and then went on to conclude that, given the insane amount of uncertainty and confusion about what Donald Trump, Tom Price and the Congressional GOP in general has in mind for the 2018 insurance market, on top of normal stuff like inflation, an aging population and so on, that there are five likely scenarios:

Now, put yourself in the position of an insurance carrier executive and/or one of their actuaries. The level of uncertainty in the air is mind boggling. You have five choices for your initial filing:

For all the details, see this piece by Jonathan Cohn; the short version is that, if Trump does this, premiums could skyrocket and insurers could flee the individual markets, causing them to melt down and ultimately pushing millions off coverage. As Cohn notes, Trump is basically “threatening to torpedo insurance for millions of Americans unless Democrats agree to negotiate with him.”

The Trump administration says it is willing to continue paying subsidies to health insurance companies under the Affordable Care Act even though House Republicans say the payments are illegal because Congress never authorized them.

The statement sends a small but potentially significant signal to insurers, encouraging them to stay in the market.

In additon to color-coding their data by the political party of each District's Representative, I'm also adding my own spin on the data: Estimates of how many people currently enrolled in the individual market suffer from "pre-existing conditions" which would likely mean them either being denied coverage altogether if the ACA's Guaranteed Issue, Essential Health Benefits and Community Rating provisions were to be stripped (Alternately, these people would charged massively higher rates to the point of likely not being able to afford the policy).

Last fall, when the insurance carriers were jacking up their rates on the individual market by an (unsubsidized) national weighted average of around 25%, aside from the understandable grumbling about such a dramatic all-at-once increase, the big question was whether that would be enough to stabilize the market going forward, or whether this was just the beginning of an inevitable Death Spiral, etc etc.

An analysis out Thursday says that health insurers are expected in 2016 "to start reversing" financial losses on their Obamacare business after "hitting bottom" in 2015.

And 2017 "will likely see continued improvement" for those insurers selling individual health plans, "with more insurers getting close to breakeven or better," according to the report by Standard and Poor's Global Ratings.

The report also says big price increases for Obamacare plans in 2017 were likely a "one-time pricing correction."

Ever since I started this venture, one of the most difficult types of data for me to hunt down have been the ever-elusive off-exchange individual market enrollment numbers.

Off exchange data is extremely difficult to come by for several reasons. First, because unlike enrollments via the ACA exchanges, off-exchange enrollment data is a purely private transaction between individuals and private corporation. Yes, publicly traded companies have to provide some level of data in their quarterly & annual reports, but that data usually focuses on the financial side. Yes, they generally do give some info about how many enrollees they have, but they don't always break out the individual market specifically...and when they do, they often don't distinguish between the on and off-exchange numbers. Finally, even when they do break it out into that much detail, you'll be hard pressed to find a carrier who breaks the numbers out by state (unless they only operate in one or two states to begin with).

OK, I was about to go with the more obvious saying: "Sh*t or get off the pot", but I'm trying to avoid blatant profanity in the headlines, at least.

Here's a tweetstorm from fomer director of the Centers for Medicare & Medicaid, Andy Slavitt, from yesterday/continuing through today. He confirms everything I've been sounding the alarm about, especially regarding the CSR payment crisis:

One of the questions I get asked most frequently is why don't more health plans speak up about what a disaster AHCA would be. 1

A new Kaiser Family Foundation analysis finds that the average premium for a benchmark silver plan in Affordable Care Act (ACA) marketplaces would need to increase by an estimated 19 percent for insurers to compensate for lost funding if they don’t receive federal payment for ACA cost-sharing subsidies.

The efforts to replace the Affordable Care Act have caused worry for insurers, who aren’t sure about the law’s future or what would replace it. On Thursday, Aetna Inc. said it would pull out of Iowa’s Obamacare market, becoming the second major health plan to do so this week after Wellmark Inc. said it was quitting the state as well.

“Aetna will not participate in the Iowa individual public exchange for 2018 as a result of financial risk and an uncertain outlook for the marketplace,” spokesman T.J. Crawford said in an email Thursday. “We are still evaluating Aetna’s 2018 individual product presence in our remaining states.”

...Many Republicans would prefer to argue the Obamacare markets were already in their death throes before they took charge — the question is whether they can get away with it.

“The first question I think they’re trying to figure out is, do we actually own it for 2018?” said one health care lobbyist, speaking on background. “If premiums spike and plans exit, can we still blame it on Obama and get away with it? That’s one of the threshold questions that I don’t think they’ve answered.”

there's some positive news for Iowa, at least; as noted by Cynthia Cox and reported on by Tony Leys of the Des Moines Register, Wellmark is joining the Iowa exchange next year:

Iowa’s dominant health insurer has agreed to start selling policies a year from now that qualify for Obamacare subsidies.

Wellmark Blue Cross & Blue Shield has not participated in the Affordable Care Act’s online health insurance marketplace, which launched in the fall of 2013. The main effect of the company’s decision was that moderate-income Iowans could not choose Wellmark insurance if they wanted to purchase policies that qualified for new federal subsidies to help pay premiums.

Immediately after the "death" of the AHCA (Trumpcare) bill, I posted the clip above (from the underrated suspense thriller "Dead Again"), noting that as much of a victory as it was, there was little time to pat ourselves on the back, because Trump and the GOP would no doubt be back for Round 2 at any moment.

At the time, I assumed that they would likely abandon the "official" attempt at repeal/replace for the time being, and focus instead "only" on sabotage efforts of the ACA itself by doing whatever they can to scare off the carriers...and for the most part, that's exactly what Trump has done ("It's gonna explode!" and so forth).

You may have noticed that among my 16 recommendations for repairing/improving the ACA, I foolishly failed to include one of the most important/obvious ones: Reinsurance. I didn't include it for two reasons: Partly because, quite frankly, I simply forgot about it and feel bad about myself now.

So far, two states (Alaska and Minnesota) have already established their own state-based reinsurance programs; in both cases, it was done as an act of sheer desperation...and, in both cases were put through in a bipartisan fashion (both states have GOP-held legislatures, but Minnesota's Governor is Democratic while Alaska's is Independent):

There was a time, just a few months ago, when it looked like Alaska, which had already suffered from massive rate hikes the past 2 years due to their unique healthcare situation, might have a complete catastrophe on their hands with a third year of massive individual market rate hikes.

...the assumption is that as long as insurance carriers either a) know they'll make a profit in a given market or b) think they'll make a profit at some point in the near future, they'll participate in that market, right?

However, that's not necessarily the case. As we saw last year in the case of Aetna, profitability itself doesn't necessarily guarantee participation. Aetna pulled out of 11 states, and while they were losing money on the indy market in most of them, there were at least 2 states (Pennsylvania and Florida) where they were making a profit, yet bailed anyway. In fact, in Florida, the only reason they were making a profit in the indy market was because of their exchange business (they were losing money off-exchange).

I see that I've been thrown into the crossfire of a wonk debate between John Cochrane (who I've never actually heard of before today) and Brad DeLong/Paul Krugman (both of whom I very much have heard of!) regarding the question of whether the individual healthcare market is or isn't in a Death Spiral and/or whether it will/won't enter one next year.

Of course, as I (and others on both sides of the political spectrum) have written about many, many times, not everyone who selects a QHP (either on or off the exchanges) actually pays their first premium, and therefore is never actually enrolled in an active, effectuated policy. This amounted to roughly 12-13% of all QHP selections in 2014, but has improved over the past 3 years as people got used to how the system works and technical improvements were made. I've been using a 10% non-payment rate as a general rule of thumb for some time now.